Care-seeking experiences of unattached patients in the Canadian health care system: Qualitative study.

OBJECTIVE: To understand how lack of attachment to a regular primary care provider influences patients' outlooks on primary care, ability to address their health care needs, and confidence in the health care system. DESIGN: Qualitative descriptive study using semistructured interviews. SETTING: Canadian provinces of Nova Scotia, Ontario, and Quebec. PARTICIPANTS: Patients aged 18 years or older who were unattached or had become attached within 1 year of being interviewed and who resided in the province in which they were interviewed. METHODS: Forty-one semistructured interviews were conducted, during which participants were asked to describe how they had become unattached, their searches to find new primary care providers, their perceptions of and experiences with the centralized waiting list in their province, their experiences seeking care while unattached, and the impact of being unattached on their health and on their perceptions of the health care system. Interviews were transcribed and analyzed using a thematic approach. MAIN FINDINGS: Two main themes were identified in interviews with unattached or recently attached patients: unmet needs of unattached patients and the impact of being unattached. Patients' perceived benefits of attachment included access to care, longitudinal relationships with health care providers, health history familiarity, and follow-up monitoring and care coordination. Being unattached was associated with negative effects on mental health, poor health outcomes, decreased confidence in the health care system, and greater pre-existing health inequities. CONCLUSION: Having a regular primary care provider is essential to having access to high-quality care and other health care services. Attachment also promotes health equity and confidence in the public health care system and has broader system-level, social, and policy implications.

A typology of social network interactions in sub-Saharan Africa: Evidence from a rural population in Senegal.

Social isolation/marginalization in sub-Saharan Africa is under-researched, despite increasing evidence of weakening traditional community-based social support. This paper aims to develop a typology of social networks capable of accounting for social marginalization in a rural community in Western Senegal and to describe the socio-demographic characteristics of network profiles. Building on prior qualitative work, we carry out a latent profile analysis using a unique and extensive social network data set, identifying four different network profiles: Locally integrated, Constrained relationships, Locally marginalized, and Local elites. This paper provides the first empirically supported classification of social integration and marginalization in social networks in rural sub-Saharan Africa. In doing so, it can serve as a reference for future research seeking to understand both the broader scope of social integration and marginalization and the consequences of differential access to social capital through social networks on access to health resources and well-being.

Does social integration really protect against loneliness? Gender determinants in a rural population in Senegal / L'intégration sociale protège-t-elle vraiment contre la solitude ? Déterminants genrés dans une population rurale du Sénégal

Introduction: This study aims to test a measure of loneliness and to document its determinants among rural men and women in Senegal. Methods: Data from the Niakhar Social Networks and Health Project were used. The analysis sample was composed of 1261 residents aged 16 years and older. Analyses were stratified by gender. Associations between loneliness and its determinants (socio-demographic characteristics and level of social integration) were examined with multivariate logistic regressions. Results: Loneliness affects almost one in three people. Its prevalence is more significant for women. Multivariate analyses indicate that for both men and women, older age intensifies loneliness and recent migration experience protects against loneliness. Other factors act differently according to gender. Widowhood or divorce for men, and residential isolation for women, worsen the experience of loneliness. Social integration protects men against loneliness, but this relationship is not found for women. Finally, the effect of the level of social integration on loneliness varies with age. Conclusions: This study, which documents a phenomenon which is often neglected by misconceptions about social solidarities in these societies, suggests that loneliness is not linked to the same issues for men and women. For men, being socially integrated and being in a union are protective, whereas for women, poor social integration does not appear to be a clear source of loneliness, unlike residential isolation.

Introduction: Cette étude vise à tester une mesure de la solitude et à documenter ses déterminants chez les hommes et les femmes en milieu rural au Sénégal. Méthodes: Les données du Niakhar Social Networks and Health Project sont utilisées. L'échantillon d'analyse est composé de 1 261 résidents âgés de 16 ans et plus. Les analyses sont stratifiées par sexe. Les associations entre la solitude et ses déterminants (caractéristiques socio-démographiques et niveau d'intégration sociale) sont examinées à l'aide de régressions logistiques multivariées. Résultats: La solitude touche près d'un individu sur trois et sa prévalence est plus grande chez les femmes. Les analyses multivariées indiquent que, pour les hommes et les femmes, l'âge avancé favorise la solitude, et l'expérience migratoire récente protège contre la solitude. D'autres facteurs agissent de manière différente selon le sexe. La situation de veuvage ou de divorce pour les hommes, et l'isolement résidentiel pour les femmes, entrainent l'expérience de solitude. L'intégration sociale protège les hommes contre la solitude, mais cette relation ne se retrouve pas pour les femmes. Enfin, l'effet du niveau d'intégration sociale sur la solitude varie selon l'âge. Conclusion: Cette étude suggère que la solitude ne répond pas aux mêmes enjeux pour les hommes et pour les femmes et documente ce phénomène souvent occulté par les idées reçues relatives aux solidarités sociales dans ces sociétés. Pour les hommes, être intégrés socialement et être en union sont des éléments protecteurs, alors que pour les femmes, une faible intégration sociale n'apparait pas clairement comme une source de solitude, contrairement à l'isolement résidentiel.

Use of Electronic Medical Record Data to Create a Dashboard on Access to Primary Care.

Objective: This study aims to present a proof of concept of a dashboard on a set of indicators of access to primary healthcare (PHC) based on electronic medical records (EMRs). Methods: This research builds on a multi-method design study including (1) a systematic review, (2) a pilot phase and (3) the development of a dashboard. Results: Eight indicators were carefully selected and successfully extracted from EMRs obtained from 151 PHC providers. Indicators of access over time, as well as among providers and among clinics, have been enabled in the dashboard. Conclusion: EMR data enabled the development of a real-time dashboard on access, giving PHC providers a reliable portrait of their own practice, its evolution over time and how it compares with those of their peers.

Strategies used throughout the scaling-up process of eConsult - Multiple case study of four Canadian Provinces.

BACKGROUND: eConsult is a model of asynchronous communication connecting primary care providers to specialists to discuss patient care. This study aims to analyze the scaling-up process and identify strategies used to support scaling-up efforts in four provinces in Canada. METHODS: We conducted a multiple case study with four cases (ON, QC, MB, NL). Data collection methods included document review (n = 93), meeting observations (n = 65) and semi-structured interviews (n = 40). Each case was analyzed based on Milat's framework. RESULTS: The first scaling-up phase was marked by the rigorous evaluation of eConsult pilot projects and the publication of over 90 scientific papers. In the second phase, provinces implemented provincial multi-stakeholder committees, institutionalized the evaluation, and produced documents detailing the scaling-up plan. During the third phase, efforts were made to lead proofs of concept, obtain the endorsement of national and provincial organizations, and mobilize alternate sources of funding. The last phase was mainly observed in Ontario, where the creation of a provincial governance structure and strategies were put in place to monitor the service and manage changes. CONCLUSIONS: Various strategies need to be used throughout the scaling-up process. The process remains challenging and lengthy because health systems lack clear processes to support innovation scaling-up.

Evaluation of the implementation of single points of access for unattached patients in primary care and their effects: a study protocol.

INTRODUCTION: Attachment to a primary care provider is an important component of primary care as it facilitates access. In Québec, Canada, attachment to a family physician is a concern. To address unattached patients' barriers to accessing primary care, the Ministry of Health and Social Services mandated Québec's 18 administrative regions to implement single points of access for unattached patients (Guichets d'accès première ligne (GAPs)) that aim to better orient patients towards the most appropriate services to meet their needs. The objectives of this study are to (1) analyse the implementation of GAPs, (2) measure the effects of GAPs on performance indicators and (3) assess unattached patients' experiences of navigation, access and service utilisation. METHODS AND ANALYSIS: A longitudinal mixed-methods case study design will be conducted. Objective 1. Implementation will be analysed through semistructured interviews with key stakeholders, observations of key meetings and document analysis. Objective 2. GAP effects on indicators will be measured using performance dashboards produced using clinical and administrative data. Objective 3. Unattached patients' experiences will be assessed using a self-administered electronic questionnaire. Findings for each case will be interpreted and presented using a joint display, a visual tool for integrating qualitative and quantitative data. Intercase analyses will be conducted highlighting the similarities and differences across cases. ETHICS AND DISSEMINATION: This study is funded by the Canadian Institutes of Health Research (# 475314) and the Fonds de Soutien à l'innovation en santé et en services sociaux (# 5-2-01) and was approved by the CISSS de la Montérégie-Centre Ethics Committee (MP-04-2023-716).

COVID-19 - an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada).

BACKGROUND: COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia. METHODS: We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models. RESULTS: We identified and analyzed six organizational innovations. Four of these - centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults - pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations. CONCLUSION: COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

CUP study: protocol for a comparative analysis of centralised waitlist effectiveness, policies and innovations for connecting unattached patients to primary care providers.

INTRODUCTION: Access to a primary care provider is a key component of high-functioning healthcare systems. In Canada, 15% of patients do not have a regular primary care provider and are classified as 'unattached'. In an effort to link unattached patients with a provider, seven Canadian provinces implemented centralised waitlists (CWLs). The effectiveness of CWLs in attaching patients to regular primary care providers is unknown. Factors influencing CWLs effectiveness, particularly across jurisdictional contexts, have yet to be confirmed. METHODS AND ANALYSIS: A mixed methods case study will be conducted across three Canadian provinces: Ontario, Québec and Nova Scotia. Quantitatively, CWL data will be linked to administrative and provider billing data to assess the rates of patient attachment over time and delay of attachment, stratified by demographics and compared with select indicators of health service utilisation. Qualitative interviews will be conducted with policymakers, patients, and primary care providers to elicit narratives regarding the administration, use, and access of CWLs. An analysis of policy documents will be used to identify contextual factors affecting CWL effectiveness. Stakeholder dialogues will be facilitated to uncover causal pathways and identify strategies for improving patient attachment to primary care. ETHICS AND DISSEMINATION: Approval to conduct this study has been granted in Ontario (Queens University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board, file number 6028052; Western University Health Sciences Research Ethics Board, project 116591; University of Toronto Health Sciences Research Ethics Board, protocol number 40335), Québec (Centre intégré universitaire de santé et de services sociaux de l'Estrie, project number 2020-3446) and Nova Scotia (Nova Scotia Health Research Ethics Board, file number 1024979).

Telehealth challenges during COVID-19 as reported by primary healthcare physicians in Quebec and Massachusetts.

BACKGROUND: The COVID-19 pandemic has driven primary healthcare (PHC) providers to use telehealth as an alternative to traditional face-to-face consultations. Providing telehealth that meets the needs of patients in a pandemic has presented many challenges for PHC providers. The aim of this study was to describe the positive and negative implications of using telehealth in one Canadian (Quebec) and one American (Massachusetts) PHC setting during the COVID-19 pandemic as reported by physicians. METHODS: We conducted 42 individual semi-structured video interviews with physicians in Quebec (N = 20) and Massachusetts (N = 22) in 2020. Topics covered included their practice history, changes brought by the COVID-19 pandemic, and the advantages and challenges of telehealth. An inductive and deductive thematic analysis was carried out to identify implications of delivering care via telehealth. RESULTS: Four key themes were identified, each with positive and negative implications: 1) access for patients; 2) efficiency of care delivery; 3) professional impacts; and 4) relational dimensions of care. For patients' access, positive implications referred to increased availability of services; negative implications involved barriers due to difficulties with access to and use of technologies. Positive implications for efficiency were related to improved follow-up care; negative implications involved difficulties in diagnosing in the absence of direct physical examination and non-verbal cues. For professional impacts, positive implications were related to flexibility (teleworking, more availability for patients) and reimbursement, while negative implications were related to technological limitations experienced by both patients and practitioners. For relational dimensions, positive implications included improved communication, as patients were more at ease at home, and the possibility of gathering information from what could be seen of the patient's environment; negative implications were related to concerns around maintaining the therapeutic relationship and changes in patients' engagement and expectations. CONCLUSION: Ensuring that health services provision meets patients' needs at all times calls for flexibility in care delivery modalities, role shifting to adapt to virtual care, sustained relationships with patients, and interprofessional collaboration. To succeed, these efforts require guidelines and training, as well as careful attention to technological barriers and interpersonal relationship needs.

Neighbourhood community life and health: A systematic review of reviews.

Neighbourhood community life has been widely recognized as an important determinant of population health. This systematic review of reviews provides an overview of the evidence for the ecological correlation between neighbourhood community life and population health. Nine databases were searched from 2008 to 2018 in order to identify systematic reviews of studies examining the association between neighbourhood community life and population health in urban neighbourhoods within the Organisation for Economic Co-operation and Development countries. Two reviewers completed selection and data extraction, then assessed the methodological quality of reviews using the Measurement Tool to Assess Systematic Reviews. We identified three high quality reviews and five of moderate quality. The reviews vary in quality of methodology, concepts, and measures. Most of the reviews examined the influence of social cohesion, social capital, and social interactions on health. Reviews found evidence supporting a consistently favourable correlation between social cohesion and physical activity, as well as a favourable trend in the relationship between social cohesion and healthy weight. They also found evidence of a favourable trend in the correlation between social capital and healthy weight. Reviews identified studies supporting a consistently favourable correlation between social interaction and depression. We identify evidence of a positive association between neighbourhood community life and several population health outcomes. Future research should define and conceptualize neighbourhood community life factors and health indicators to improve the comparison between studies and the process of evidence synthesis. This will also enable policy makers to take appropriate decisions.